NATIONAL FRAMEWORK
OF STANDARDS FOR ORGANISATIONS PROVIDING OUT-OF-HOURS EMERGENCY CARE

Summary

1. Attached is a
revised and updated version of the National Framework of Standards for
Organisations Providing Out of Hours Care which takes account of recommendations
contained in the Review of GP Out of Hours Services published in October
1998.

2. Implementation
of the Review's recommendations continues:

The Scottish Out
of Hours Study Group have been working on a project to assess the quality
and cost effectiveness of current out of hours services and they will
report in the summer;

The Royal College
of General Practitioners are developing an accreditation system for
out of hours providers; and

The University
of Edinburgh is developing a national patient satisfaction survey which
will be available for use by all out of hours organisations.

This framework may
therefore be subject to further revision once the outcome of these pieces
of work are known.

Action

3. Primary Care Trust
Chief Executives are asked to ensure that copies of the framework are
distributed to Out of Hours Co-operatives, deputising services and GP
practices which operate a rota system for providing out of hours services.

NATIONAL
FRAMEWORK OF STANDARDS FOR ORGANISATIONS
PROVIDING OUT-OF-HOURS EMERGENCY CARE

Paragraph 19 of the Terms of Service for Doctors, as amended, sets out
the responsibilities of a doctor who is making use of an organisation
providing deputy doctors to ensure that the organisation provides a
service which is adequate and appropriate for his or her patients. GPs
will wish to ensure that any organisation providing out-of-hours care
sets standards for the care which it provides, both to inform its members
or subscribers of those standards and of its performance against those
standards, and to allow it to audit its own activity.

This
document sets out a framework against which locally appropriate standards
should be defined, and includes brief guidance notes which should assist
with that definition. Primary Care Trusts Boards and GPs should, in
principle, apply the same standards to judging the performance of all
forms of GP out of hours care.

GPs
will wish to ensure that organisations set standards in relation to
the following aspects of the care which they provide.

i.
Competence of the Doctors on Duty

The
competence of the doctors on duty is governed by the provisions of paragraphs
18, 19 and 20 of the Terms of Service for Doctors. In particular, paragraph
20(1) states that a deputy must be suitably experienced within the meaning
of Section 21 of the National Health Service (Scotland) Act 1978 (other
than by virtue of being a restricted services principal), or have the
acquired right specified in regulation 5(1)(d) of the Vocational Training
for General Medical Practice (European Requirements) Regulations 1994,
or be a trainee general practitioner.

The doctors
on duty should be able to provide the full range of services normally
provided by GPs out-of-hours.

ii.
Adequacy of Service

Primary Care
Trusts are required to ensure that any GP out of hours arrangement
in their area includes appropriate arrangements to ensure quality
and responsiveness of service. The number of doctors on active duty
and their deployment should be adequate having regard to the emergency
care needs of the population to be covered and the nature of the area.
The organisation should specify to its members or subscribers the
geographical area which it covers, for example, by using postcodes,
or by reference to a map.

The organisation should inform its members or subscribers if it is
no longer able to provide a service for whatever reason. As much notice
should be given as the circumstances allow. Arrangements for handing
back calls to participating practices during emergencies and crises
should be set out clearly.

iii. Transfer
of Clinical Information to and from a Patient's Own Doctor

There should be
arrangements for the transmission to the patient's own doctor of written,
faxed or e-mailed reports concerning the service provided to a patient,
which should include the duty doctor's assessment and information about
any treatment or necessary follow-up.

Reports should normally be made available to the patient's own doctor
as soon as is reasonably possible. Where it is judged that the patient's
own doctor might wish to take action more quickly, information should
also be provided by telephone or NHSnet e-mail.

There should be arrangements for members or subscribers to supply duty
doctors in advance with information about seriously ill patients or
other patients with special needs. Any arrangements for handing back
particular calls to members or subscribers should be set out.

iv. Supporting
Staff Engaged by the Organisation

Members
or subscribers should be advised of the nature of any supporting staff
engaged by the organisation, and where and by whom those supporting
staff are indemnified for their acts and omissions. Members or subscribers
should also be advised of any protocols used by supporting staff.

v.
Transport Arrangements for Doctors

Members
or subscribers should be informed of the nature of any transport provided
for the doctors on duty and of whether the doctors are accompanied by
a driver.

vi.
Communications with the Doctors Providing Clinical Care

The
nature of the communication system or systems used by the doctors providing
clinical care should be specified to the members or subscribers.

vii.
Information

All organisations
should have in place clear standards and systems for:

case
recording, including hand-over to the daytime service and feedback
to the patient's own GP;

confidentiality;

audit
trails in case of questions or complaints

viii. Communications
with Patients

All out
of hours organisations should have a strategy to ensure that patients
are clearly informed about access to out of hours care and how services
are arranged and should look for regular opportunities to increase the
patient understanding of their service. The organisation should specify
how patients or their representatives are to access the service in an
emergency, and whether an answering service or machine is used. Health
Boards should ensure that no out of hours service in their area requires
more than two telephone calls for patients to access it and that all such
service providers are working towards contact via a single telephone call.
Different arrangements may be appropriate at the beginning and end of
shifts to avoid over-burdening of the out of hours organisation with calls
intended for practices.

Services should have a clear policy for handling calls from telephone
boxes which ensures that they are handled quickly.

The organisation should also specify how it will obtain patients' views
on the service.

ix. Prioritising
Cases

Organisations
should establish clear protocols for staff answering calls. The protocols
should include the responsibilities of staff in relation to responding
to, prioritising and passing on calls. This may include guidance on
what information to collect or on particular symptoms which require
a quick referral to clinical staff. Where guidelines are used. organisations
should ensure that their introduction, use and any changes are backed
up by appropriate training.

x.
Arrangements for giving Advice, for Primary Care Centre Consultations
and for Home Visiting

The
organisation's operational arrangements should be set out. The increasing
emphasis on evidence-based medicine across the NHS is as relevant to
out of hours organisations as it is to other areas of the NHS and clinical
guidelines on best practice in handling particular conditions, where
they are available, should be used by clinicians in organisations to
support and demonstrate consistent delivery of best practice. Where
guidelines are used, organisations should ensure that their introduction,
use and any changes are backed up by appropriate training.

xi.
Recording of Requests for Care and of Action Taken

The
organisation should record requests for care and the action taken in
response to those requests, using a clerical or computerised system
which can operate separately from the clinical records. This should
allow the analysis of individual requests for care and the action taken
in response, and would also enable appropriate analysis of aggregated
data concerning demands on the service and responses to those demands.
Any computerised system should if possible include a secure audit trail
to prevent data erasure and to record the date, time and author of data
entries and alterations.

xii.
Vulnerable Patient Groups

The
organisation should monitor particularly carefully their treatment of
vulnerable patient groups for example, children, the elderly or the
terminally ill, including the reasons for calls and the type of consultation
given. The organisation should also make full use of the information
gathered through reviewing complaints and critical incidents.

xiii.
Working Patterns

It
is important that all organisations have clear arrangements for back
up cover in case of emergency. All organisations should have clear protocols
which include trigger factors for calling additional help. Out of hours
care is primarily a night time service, and many staff will also have
day time commitments, organisations should therefore have policies which
seek to ensure that the quality of care is not compromised by tired
out staff.

xiv.
Team Working

Regular
multi-disciplinary meetings and discussions are likely to be particularly
important to organisations given the use of a large and varying team.
Organisations should also make full use of critical incident reviewing
with staff so that the organisation learns from problems or complaints.

xv.
Clinical Audit

Organisations
should participate in systematic clinical audit and have systems of
clinical governance which are consistent with those of local LHCCs and
PCTs.

xvi.
Review of Clinical Practice

All
organisations should have systems in place for discussion and feedback
on clinical issues between participating GPs.

xvii.
External Relationships

Organisations
should set out their arrangements for co-ordination with care provided
by hospital accident and emergency departments, out of hours, Scottish
Ambulance Service, community nursing, mental health and social work
teams.

xviii.
Complaints

Information should
be collated concerning complaints about the service and any appropriate
action taken following the investigation of those complaints.

Arrangements
should be in place to ensure that doctors on duty and members or subscribers
will co-operate with the patient's own doctor, to adhere to the national
requirements of the NHS complaints procedures, in the investigation
of any complaint made about the service provided, and that any appropriate
remedial action is implemented.

xix.
Remedial Notices

The
organisation should collect information concerning remedial notices
served by a Primary Care Trust, and any remedial action taken to correct
identified service deficiencies.

xx.
Accountability

As a matter of
routine, each organisation should be able to report its performance
on

the
average and the range of waiting times in emergency centre

the
average and the range of response times for emergency and non-emergency
home visits

time taken to answer or return calls

patient
satisfaction levels

adherence
to administrative protocols

number, handling and outcome of complaints

All out of hours organisations
should produce an annual report which should cover core data including
workload, proportion of calls dealt with in different ways, patient response,
performance against any standards or targets set and complaints. The annual
report should be submitted to the relevant Primary Care Trust and be available
to patients.